Dental and Denturist Program Replacement Page, July 2002
Procedure Limits and Requirements (continued)
These codes include only procedures that have a descriptive limitation or requirement.
Code Procedure Limitation or Requirement Age
Description Restrictions
D4355 Full mouth debride- • To be used prior to periodontal scaling and root plan- No
ment to enable com- ing only if provider cannot determine extent of peri-
prehensive odontal scaling and root planing without this
periodontal evalua- procedure.
tion and diagnosis. • Limited to once per year if medically indicated.
D4910 Periodontal mainte- • To be used after initial periodontal scaling and root No
nance procedures planing completed.
• Limited to once every three months if medically indi-
cated.
D5110 Complete upper Call Provider Relations to verify if Medicaid has paid No
dentures within the past 10 years.
D5120 Complete lower Call Provider Relations to verify if Medicaid has paid No
dentures within the past 10 years.
D5130 Immediate upper • Includes limited follow-up care only. No
• Does not include required future rebasing/relining
procedures.
D5140 Immediate lower • Includes limited follow-up care only. No
• Does not include required future rebasing/relining
procedures.
D5211 Maxillary partial den- • Includes acrylic resin base denture with resin or No
ture – Resin Base wrought iron clasps.
(including any con- • Partial dentures will only be replaced every 5 years.
ventional clasps, rests
and teeth)
D5212 Mandibular partial • Includes acrylic resin base denture with resin or No
denture – Resin Base wrought iron clasps.
(including any • Partial dentures will only be replaced every 5 years.
conventional clasps,
rests and teeth)
D5213 Maxillary partial den- • Includes any conventional clasps, rests and teeth. No
ture – Cast metal • Partial dentures will only be replaced every 5 years.
framework with resin
denture bases
D5214 Mandibular partial • Includes any conventional clasps, rests and teeth. No
denture – Case metal • Partial dentures will only be replaced every 5 years.
framework with resin
denture bases
D5820 Interim partial • Use of a flipper is considered a partial denture. Ages 20 and
denture (maxillary) • Partial dentures will only be replaced every 5 years. under only
Covered Services and Limitations 1.9
2002
Replacement Page, July 2003 Dental and Denturist Program
Procedure Limits and Requirements (continued)
These codes include only procedures that have a descriptive limitation or requirement.
Code Procedure Limitation or Requirement Age
Description Restrictions
D5821 Interim partial • Use of a flipper is considered a partial denture. Ages 20 and
denture (mandibular) • Partial dentures will only be replaced every 5 years under only
D5410 Adjust complete • The first 3 adjustments after dentures are placed are No
denture – upper included in the denture price.
• Any additional or yearly adjustments can be billed
using this code.
D5411 Adjust complete • The first 3 adjustments after dentures are placed are No
denture – lower included in the denture price.
• Any additional or yearly adjustments can be billed
using this code.
D5421 Adjust partial • The first 3 adjustments after dentures are placed are No
denture – upper included in the denture price.
• Any additional or yearly adjustments can be billed
using this code.
D5422 Adjust partial • The first 3 adjustments after dentures are placed are No
denture – lower included in the denture price.
• Any additional or yearly adjustments can be billed
using this code.
D5520 Replace missing or Each additional tooth needs to be billed on separate No
broken teeth – lines with the tooth number indicated in the tooth
complete denture number column.
(each tooth).
D5610 Repair resin saddle or No teeth or metal involved. No
base
D5710 Rebase complete Dentures must be 5 years old or older. No
upper denture
(jump or duplicate)
D5711 Rebase complete Dentures must be 5 years old or older. No
lower denture
(jump or duplicate)
D5720 Rebase upper partial Dentures must be 5 years old or older. No
denture
(jump or duplicate)
D5721 Rebase lower partial Dentures must be 5 years old or older. No
denture
(jump or duplicate)
D7140 Extraction, erupted Includes local anesthesia, suturing, if needed, and rou- No
tooth or exposed root tine postoperative care.
1.10 Covered Services and Limitations
Dental and Denturist Program 2003
Replacement Page, July 2002
Procedure Limits and Requirements (continued)
These codes include only procedures that have a descriptive limitation or requirement.
Code Procedure Limitation or Requirement Age
Description Restrictions
D7210 Surgical removal of Includes cutting of gingiva and bone, removal of tooth No
erupted tooth requir- structure, and closure.
ing elevation of
mucoperiosteal flap
and removal of bone
and/or section of
tooth
D7220 Removal of impacted Occlusal surface of tooth covered by soft tissue; No
tooth – soft tissue requires mucoperiosteal flap elevation.
D7230 Removal of impacted Part of crown covered by bone; requires mucoperi- No
tooth – partially bony osteal flap elevation and bone removal.
(crown of tooth is
partially covered by
bone)
D7240 Removal of impacted Most or all of crown covered by bone; requires muco- No
tooth – completely periosteal flap elevation and bone removal.
bony (crown of tooth
is completely covered
by bone)
D7250 Surgical removal of Includes cutting of soft tissue and bone, removal of No
residual tooth roots tooth structure and closure.
(cutting procedure)
D7310 Alveoloplasty in Indicate quadrant in "Tooth Number" column: No
conjunction with LL – Lower Left
extractions UL – Upper Left
(Per quadrant) LR – Lower Right
UR – Upper Right
D7320 Alveoloplasty not in Indicate quadrant in "Tooth Number" column: No
conjunction with LL – Lower Left
extractions UL – Upper Left
(Per quadrant) LR – Lower Right
UR – Upper Right
D7340 Vestibuloplasty – Secondary epithelialization. Ages 20 and
ridge extension under only
D7350 Vestibuloplasty – Include soft tissue graft, muscle re-attachment, Ages 20 and
ridge extension revision & management of tissue. under only
Covered Services and Limitations 1.11
Replacement Page, July 2002 Dental and Denturist Program
Procedure Limits and Requirements (continued)
These codes include only procedures that have a descriptive limitation or requirement.
Code Procedure Limitation or Requirement Age
Description Restrictions
D7540 Removal of reaction- May include, but not limited to, removal of splinters, No
producing foreign pieces of wire etc., from muscle and/or bone.
bodies – musculosk-
eletal system
D7550 Sequestrectomy for Removal of loose or sloughed-off dead bone caused by No
Osteomyelitis infection or reduced blood supply.
D7911 Complicated suture – • Reconstruction requiring delicate handling of tissues No
up to 5 cm and wide under-mining for meticulous closure.
• Excludes closure of surgical incision.
D7912 Complicated suture – • Reconstruction requiring delicate handling of tissues No
greater than 5 cm and wide under-mining for meticulous closure.
• Excludes closure of surgical incision.
D7920 Skin graft Identify defect covered, location, and type of graft. Ages 20 and
under only
D7970 Excision of hyper- For edentulous client. Ages 20 and
plastic tissue, per under only
arch
D9230 Nitrous Oxide Covered for children age 12 and under. Ages 12 and
under only
D9110 Palliative (emer- Writing prescriptions, occlusal adjustments, emer- No
gency) treatment of gency examinations, and instructions for home care
dental pain – minor are not included.
procedures
D9241 IV Sedation May only be used if the client is physically or emo- No
(first 30 minutes) tionally unable to undergo the proposed treatment or
procedures using local anesthesia alone or in conjunc-
tion with oral sedation and/or nitrous oxide.
D9242 IV Sedation See limitations under procedure code D9241. No
(each additional 15
minutes)
D9310 Consultation Includes specialist consultation; should not be No
(diagnostic service reported to describe discussion of treatment plan.
provided by dentist or
physician other than
practitioner providing
treatment)
1.12 Covered Services and Limitations
Dental and Denturist Program Page, July 2003
Replacement Page, July 2002
Procedure Limits and Requirements (continued)
These codes include only procedures that have a descriptive limitation or requirement.
Code Procedure Limitation or Requirement Age
Description Restrictions
D9410 House call (also used One nursing home call per day even when multiple cli- No
for nursing home ents are seen.
visits)
D9420 Hospital call • Code is to be used when providing treatment in hos- No
pital or ambulatory surgical center, in addition to
reporting appropriate code numbers for actual ser-
vices performed.
• Code can only be billed one time per day even when
multiple clients are seen, and one of the following
conditions must be met:
• The client is unable to be managed in the office or
is medically unstable.
• Medical necessity must be documented in the cli-
ent file.
D9920 Behavior • 15 min = 1 unit of service. No
management • Code can only be billed where an office treatment
requires extraordinary effort and is the only alterna-
tive to general anesthesia.
• Includes any and all pharmacological, psychological,
Billed in 15 minute physical management adjuncts required or utilized.
units • Limit of 12 units per year.
(max 4 units per visit)
Covered Services and Limitations 1.13
Replacement Page, July 2002 Dental and Denturist Program
Date of service
Date of service is the date a procedure is completed. However, there are instances
where Medicaid will allow a date other than the completion date.
If a denture is inserted during a month when the client is not eligible, but previous
work (including laboratory work) was completed during an eligible period, the
denture claim will be allowed to be billed using the impression date rather than the
seating date as the date of service.
If a crown or bridge has been sent to the laboratory for final processing, and the
client never shows for the appointment to have the final placement, providers may
bill the date of service as the date the crown or bridge was sent to the laboratory for
final processing. However, the client must have Medicaid eligibility at the time
crown or bridge is sent to the lab. Crowns and bridges are limited to clients age 20
and under.
If a provider has opened the area for a root canal but anticipates the client will not
return for completion or is referring client to another provider for root canal com-
pletion, procedure D3220 (covered for ages 20 and under only) may be billed.
However, root canal codes must be billed to Medicaid at the time of completion.
Fee schedule
All procedures listed in the Montana Medicaid Fee Schedule are covered by the
Medicaid program and must be used in conjunction with the limits listed in the
previous section (Procedure limits and requirements). If CDT-3 codes exist and
are not listed in the Montana Medicaid Fee Schedule, the items are not a covered
service of the Medicaid program. Services that are not covered or exceed the spec-
ified limits can be billed to the client as long as the provider informs the client,
prior to providing the services, that the client will be billed. Fee schedules are
available on disk, hardcopy, or on the internet. For disk or hard copy, contact Pro-
vider Relations (see Key Contacts). The internet address for fee schedules is as
follows:
www.dphhs.state.mt.us/hpsd/medicaid/medpi/medfs/medfs.htm
Calculating service limits
Any service which is covered only at specified intervals for adults will have a
notation next to the procedure code with information about the limit (refer to pre-
Service limits
do not apply vious section Procedure limits and requirements). When scheduling appointments,
to individuals please be aware limits are controlled by our computerized claims payment system
up to and in- in this manner.
cluding age 20.
1.14 Covered Services and Limitations